The findings of the re-licensure survey, conducted 09/26/22 through 09/28/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 09/28/22, conducted 01/10/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to ensure they had effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:

a. Review of Resident Council minutes, dated 08/01/22 and 09/21/22 revealed the following resident concerns:

* "Residents feel that the food comes out cold. Residents want different options. Same things too often. Same meat in different meals. Soup too salty."

* "Residents think it would be nice if Executive Director joined them sometime for meals so they can get to know her more and feel more comfortable coming to someone they know for concerns."

* "Would love to go to a movie as an outing."

* "Some residents feel like concerns are not being heard."

There was no documented evidence that concerns identified during the meetings were addressed, responded to, or resolved.

b. On 09/27/22 at 11:00 am the surveyors conducted a group interview with residents. Several stated that concerns brought forward in resident council meetings were not addressed, responded to, or resolved.

An interview on 09/28/22 with Staff 1 (Executive Director) revealed that the facility did not currently have a process in place in which they addressed concerns identified during Resident Council meetings. Issues identified at the Resident Council meetings were discussed amongst the management team, however, resolution or follow-up was not being provided to the residents who brought forward the concerns. She acknowledged the need to improve the facility's method for responding to and resolving resident complaints.

The community acknowleged that concerns brought forward in resident council meeting were not addressed, responded to, or resolved.

The community representitive that attends resident council and takes notes, will start opening the meeting reviewing the concerns brought forward in the previous month's resident council meeting. They will discuss the changes that have been implememented to address/respond/resolve the concerns.

After each meeting the notes will be e-mailed to all department heads, so we can review the areas that need our attention and make a plan to address/respond/resolve to the concerns.

Based on observation, interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (#2) whose orders were reviewed. Findings include, but are not limited to:

Resident 2 moved into the facility in 07/2022 and had diagnoses which included insulin dependent diabetes.

MARs for Resident 2, reviewed from 09/01/22 - 09/28/22, interviews with the resident on 09/26/22 and 09/28/22, and review of the clinical record revealed the following orders were not followed:

a. S/he had an order for Nystatin powder twice a day (scheduled on the MAR for 9:00 am and 9:00 pm) for a fungal skin infection.

In an interview on 09/26/22, the resident said that staff were not applying the Nystatin.

On 09/28/22 at 11:20 am, the surveyor asked Staff 14 (MT) if Resident 2 received his/her Nystatin powder that morning. Staff 14 replied that "[s/he] gets it at noon", and it had not been applied yet. Staff 14 and the surveyor reviewed the MAR. According to the MAR, Staff 14 initialed that the Nystatin had been applied at 9:00 am that morning.

In an interview with Resident 2 at 11:35 am the same day, s/he said the Nystatin powder was not applied "this morning."

In an interview with Staff 2 (RN/Health Services Director) on 09/28/22 at 11:45 am, he reviewed the MAR and confirmed the Nystatin order had not been followed. He added that staff should not sign for treatments that were not administered.  

b. Resident 2 had orders for CBGs before meals and bedtime, Novolog insulin before meals, and Basaglar insulin at bedtime. Staff were instructed to "notify MD and RN if CBG is over 400."

The MARs revealed CBGs over 400 on 18 occasions between 09/01/22 and 09/26/22, and the MD and RN were not consistently notified.

In an interview with Staff 2 (RN/Health Services Director) on 09/28/22 at 11:45 am, he reviewed the MAR and confirmed staff had not consistently notified him of CBGs greater than 400.

c. Resident 2 had an order for bedtime CBGs and Basaglar insulin.

According to the MARs, staff failed to obtain the resident's bedtime CBG on 09/19/22 and 09/20/22.

On 09/28/22 at 11:45 am, Staff 2 checked the computer MAR and stated bedtime CBGs for 09/19/22 and 09/20/22 were not documented as done.  

The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (Executive Director) and Staff 2 during interviews on 09/28/22. The findings were acknowledged. No further information was provided.

Resident 2 The community acknowledged orders were not carried out as prescribed by PCP.

Resident 2 QMAR was updated immediately to verify if MD and RN were notified when CBGs were over 400.

Resident 2 PCP was immediately faxed for her to self-administer her Nystatin powder at her request.

Medication Techs will be re-educated on the requirement and their job duty to ensure orders are being carried out as prescribed. Employee coaching and counseling will be provided to the Medication Techs that did not notify MD and RN for CBGs over 4oo and the Medication Tech that signed for a treatment that had not been given. All re-education to be completed by 11/26/2022.

The RN will be e-mailed by QMAR every time a CBG is over 400 to ensure proper notifications were made and orders were carried out as prescribed by PCP.

Monthly sample of 5-10% of resident for MAR to order audits by health services department and quarterly pharmacy consultant reviews for QA purposes.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 1 of 3 sampled residents (#2) whose medications were reviewed. Findings include, but are not limited to:

Resident 2 was admitted in 07/2022 with diagnoses which included pain and fungal skin infections.

Resident 2's MARs were reviewed from 09/01/22 through 09/28/22 and the following was noted:

* Resident 2 had orders for Nystatin powder twice a day (for fungal infections), Diclofenac gel four times a day (for pain), and Secura cream PRN (for skin irritation). All were to be applied to "affected area(s)" or "reddened or excoriated area." The MAR lacked resident-specific instructions for the application of the powder, gel and cream.

In an interview with Staff 14 (MT) on 09/28/22 at 11:20 am, she reviewed the computer MAR and acknowledged it failed to indicate where the medications were to be applied.

During an interview on 09/28/22 at 11:50 am, Staff 2 (RN/Health Services Director) reviewed the MAR and acknowledged the Nystatin, Diclofenac gel, and Secura cream lacked specific application instructions for staff.

The need to ensure MARs were accurate and included required information was discussed with Staff 1 (Executive Director) on 09/28/22. She acknowledged the findings. No further information was provided.

The community acknowledges failure to ensure MARs were accurate for 1 of 3 sampled residents whose medications were reviewed.

Resident 2 had orders for Nystatin powder twice a day (for fungal infections), Diclofenac gel four times a day (for pain), and Secura cream PRN (for skin irritation). All were to be applied to "affected area(s)" or "reddened or excoriated area." The MAR lacked resident-specific instructions for the application of the powder, gel and cream.

RN immediately updated MAR to add directions that this specific resident is able to self-direct location.

All residents medications will be reviewed to ensure their MAR reflects resident specific instructions for staff prior to administration by 11/26/2022.

Med Techs will be re-educated on PRN medications; the need to ensure MARs are accurate, resident specific instructions, that the MAR is followed and documentation.

HSD/Memory Care Director to oversee the compliance with MAR accuracy, documentation, the need to ensure MARs are accurate and include all required information

HSD or Designee to oversee compliance with QMAR audits quarterly.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 veteran direct care staff (#6) completed a minimum of 12 hours of in-service training annually including six hours on dementia care. Findings include, but are not limited to:

Review of the facility's training records on 09/27/22 and 09/28/22 revealed the following:

*Training records dated 07/2021 to 07/2022 were reviewed. Staff 6 (MT) hired on 07/01/15 did not have documented evidence of six hours of annual in-service training related to dementia care.

The need to ensure that all staff had a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a CBC, including on dementia care topics was discussed with Staff 1 (Executive Director) 09/28/22.  She acknowledged the findings.

Community acknowledges incomplete staff training records for 1 of 3 veteran direct care staff completed a minimum of 12 hours of in-service training annually including six hours on dementia care.

Monthly Sample of 5-10% employee records will be audited by BOM for QA purposes. BOM has also created a tracking spreadsheet to ensure completion of required staff training.

All re-education and missing staff training records to be completed by 11/26/2022.  

Based on observation and interview, it was determined the facility failed to ensure exterior material and surfaces were in good repair for the health and safety of the residents.  Findings include, but are not limited to:

Observations of the facility on 09/26/22 revealed the following:

* The 2nd floor outdoor deck flooring materials separated creating wide gaps between one to three inches in some areas that required repair for safety.

The facility was toured with Staff 1 (Executive Director) on 09/26/22 at 11:45 am. She acknowledged the findings.

On 09/27/22 Staff 1 informed the survey team that notice had been posted on the doors leading to the deck and access to the 2nd floor deck had been restricted to abate any safety concerns until flooring materials could be repaired or replaced.

Community acknowledges failure to ensure exterior material and surfaces were in good repair for the health and safety of the residents.

The 2nd floor outdoor deck flooring materials separated creating wide gaps between one to three inches in some areas that required repair for safety.

On 09/27/22 ED informed the survey team that notice had been posted on the doors leading to the deck and access to the 2nd floor deck had been restricted to abate any safety concerns until flooring materials could be repaired or replaced.

Community has hired a contractor that will start replacing the 2nd floor outdoor deck flooring as soon as they receive the materials. Project is anticipated to start at the beginning of November 2022.

ED and ESD to conduct routine community physical plant inspections at least monthly to check for areas needing repairs/replacements.